Complications after concomitant bilateral total knee arthroplasty in elderly patients.

OBJECTIVE: To determine the risks associated with performance of bilateral total knee arthroplasty (TKA) in elderly patients. MATERIAL AND METHODS: Ninety-eight patients with osteoarthritis who were 80 years of age or older and underwent concomitant cemented bilateral TKA were matched (on the basis of gender, surgeon, year of surgical treatment, age, and diagnosis) with 98 patients who underwent cemented unilateral TKA to compare the number and types of complications in these two groups. The groups did not differ in the number and type or severity of premorbid medical conditions, anesthetic risk, and type of anesthesia. RESULTS: One hundred nineteen postoperative complications occurred in 63 patients in the bilateral TKA group; in contrast, 72 complications occurred in 49 patients in the unilateral TKA group. The difference between the two groups in the total number of complications was significant. Specifically, significant differences between the two groups were noted in the occurrence of cardiovascular and neurologic complications. On paired analysis, congestive heart failure and acute delirium were found to be significantly more frequent in the bilateral TKA group than in the unilateral TKA group. We noted a trend toward an increased mortality rate in the bilateral group (four patients) versus the unilateral group (no deaths). CONCLUSION: Patients 80 years of age or older who undergo concomitant bilateral TKA are at increased risk for cardiovascular and neurologic complications during the postoperative period in comparison with matched patients who undergo unilateral TKA.

Relationship between mortality rates and hospital patient volume for Medicare patients undergoing major orthopaedic surgery of the hip, knee, spine, and femur.

This study examines the relationship between mortality rates and hospital patient volume for major orthopaedic surgery. All Medicare patients from fiscal years 1993 and 1994 in diagnosis-related groups (DRGs) 209, 210, and 214 were included, covering hip and knee arthroplasty, other hip and femur procedures, and spine procedures. Within DRG 209, five procedures were studied in more detail: total hip arthroplasty, partial hip arthroplasty, revision total hip arthroplasty, total knee arthroplasty, and revision total knee arthroplasty. Higher-volume hospitals had lower mortality rates, both in-house and in-house plus 30-day, for each of the DRGs studied and for each of the individual procedures within DRG 209. Age and sex were examined as potential causes of the differences in mortality rates, but no attempt was made to adjust for comorbidities or orthopaedic degree of difficulty. Results for 1995 are included in an appendix.

[Expenses and risk of artificial knee joint: a look backward to a 20-year clinical experience]. / Aufwand und Risiken künstlicher Kniegelenke: Rückblick auf 20 Jahre praktische Erfahrung.

Costs and risks of implantation of prosthetic knee joints are analyzed in this retrospective study. From 1974-1993 514 primary and 34 revision arthroplasties were done in this hospital, all by the same surgeon. 98% of the patient protocols were available and analyzed, but no systematic follow-up was attempted. 82% of the patients were female; mean age at operation was 74 years. Joint destruction was caused by osteoarthritis in 75%, aseptic osteonecrosis in 10%, rheumatoid arthritis in 9% and posttraumatic arthritis in 3.5%. 75% of the patients were obese and had a body mass index > 25 kg/m2. Non-constrained unicompartmental type prostheses were used in 66%, the non-constrained multicompartmental type in 10% and the constrained total rotation knee (Engelbrecht) in 24%. Hospital mortality rate was 0.55% due to myocardial infarction and pulmonary embolism. 3 patients died of septic prosthetic joint infections 5, 7 and 71/2 years after surgery. Perioperative morbidity, typical of the age group above 70 years, was mainly due to cardiovascular and thromboembolic events and gastrointestinal bleeding. Early infection during the first postoperative year was encountered in 3 constrained total knees, but none in nonconstrained type. The calculated operative infection rate was 2.4% for the constrained type, zero for the non-constrained type, and 0.5% for the whole series. Late prosthetic infections occurred in 8 patients up to 12 years after surgery. In comparing non-constrained unicondylar and hinged types of joint replacement, the non-constrained sledge prosthesis involves considerably lower costs in terms of duration of surgery, hospital stay, blood loss, price of the implant, infection rate and difficulties of revision arthroplasty. Lower costs and risks favour the smaller unicondylar implant for use in localized degenerative or necrotic destruction, particularly of the medial compartment of the knee. Semi-constrained total condylar systems are used for more extensive degeneration without evident instability. The indication for hinged endoprostheses is restricted to revision arthroplasty and grossly unstable knees.

Survivorship analysis of the Kinematic Stabilizer total knee replacement: a 10- to 14-year follow-up.

The Kinematic Stabilizer is a posterior-cruciate-substituting design of total knee replacement. We have reviewed 109 primary total knee replacements in 95 patients at a mean follow-up time of 12.7 years (10 to 14). We used survival analysis with failure defined as revision of the implant. This gave a cumulative survival rate of 95% (95% CI +/- 5%) at ten years and (87% +/- 10%) at 13 years. These results from an independent centre confirm the value of an established design of cemented total knee replacement and question the wisdom of the introduction of modifications and new designs without properly controlled trials.

Relationship of surgical volume to short-term mortality, morbidity, and hospital charges in arthroplasty.

In 1992, the Agency of Health Care Administration in Tallahassee, Florida, started releasing, as part of the patient discharge information, the names of the treating physicians, in addition to demographic and diagnostic data. This information is available to the general public for a small price and is being used by health planners, hospital administrators, finance departments, third-party payers, and other agencies involved in health care. Patient discharge information was used to assess the effects of volume on the short-term outcome of primary and revision hip and knee arthroplasty as a function of surgeon and hospital in the State of Florida, during 1992. A total of 19,925 primary and 2,536 revision arthroplasties of the hip and knee were performed during 1992 in Florida and were available for study. After the doctors and hospitals were arbitrarily divided into three case volume groups (low, medium, high), results showed that in primary arthroplasty, surgeons with a low volume of primary cases (< 10) have a significantly higher mortality rate (24%), higher average charges ($25,000), and increased average length of hospital stay (9.3 days). In revision surgery, physicians with a low volume of cases (< 10) have a higher mortality rate (13%) and increased average length of hospital stay (9.8 days). Patients discharge information has many potential uses for investigators interested in the short-term outcome of arthroplasty. In their present form, these databases should not be released to the general public or the media. Lastly, the volume-outcome relation for a specific surgical procedure should, in addition to case severity, account for characteristics affecting the degree of technical difficulty.

Changes in mortality after total hip and knee arthroplasty over a ten-year period.

A retrospective review of in-hospital mortality after total hip and total knee arthroplasty was performed to determine whether extensive changes in anesthesia care, introduced in this institution in July 1986, were associated with changes in mortality rates. From 1981 to 1985, the mortality rate was 0.39% (23 of 5874 patients) and from 1987 to 1991, the mortality rate was 0.10% (10 of 9685 patients) (P = 0.0003). Significant reductions in mortality rate were observed for both total hip arthroplasty (from 0.36% to 0.10%) (P = 0.0277) and total knee arthroplasty (from 0.44% to 0.10%) (P = 0.0131). The mortality rate of 0.10% is significantly less than previously published rates. Marked changes in anesthesia management were associated with a significant reduction in mortality after total hip and knee arthroplasty.

Long-term survival analysis of a posterior cruciate-retaining total condylar total knee arthroplasty.

From 1975 to 1983, 278 patients received 418 posterior cruciate ligament-retaining Total Condylar knee arthroplasties. Twenty-four patients were excluded, 15 for lack of followup data, 6 for infection during followup, and 3 for revision surgeries for previous infections. The 394 remaining knees were observed from 1 to 18 years (mean, 8.08 years). Kaplan-Meier and crude survival estimates at 12 years were 96.8% and 98.1%, respectively. Various survival analyses by other authors have yielded similar successful results.

Radiolucency at the bone-cement interface in total knee replacement. The effects of bone-surface preparation and cement technique.

Three hundred and sixty-three knees (221 patients) that had been treated with total arthroplasty between 1975 and 1985 were divided into three groups on the basis of the preparation of the surface of the bone and the technique of the cement application. Group 1 (155 knees) was treated with irrigation of the bone surfaces with a syringe and manual packing of the bone cement. Group 2 (sixty-one knees) had high-volume, high-pressure lavage of the bone surfaces and manual packing of the cement. Group 3 (147 knees) had high-volume, high-pressure lavage and pressure injection of low-viscosity methylmethacrylate cement. Radiolucency was evaluated at each follow-up interval, and the findings were subjected to chi-square analysis and Kaplan-Meier survival analysis. Chi-square analysis of the data at one and three years indicated a significantly higher frequency of lines at the bone-cement interface in the femur and tibia in Group-1 knees compared with those in Groups 2 and 3. The survival curves showed increasing rates of radiolucency adjacent to the tibial components of the knees that had been prepared with lavage that was not high-volume and high-pressure and that had been prepared with finger-packing of cement (Group 1). This may partially explain the clinical problem of loosening of tibial components despite acceptable alignment. This study demonstrates that proper preparation of the cancellous bone and pressurization of the cement reduce the initial occurrence of a radiolucent line, which may have a positive effect on the ultimate failure of at least the tibial component.

Geographic variations in the rates of elective total hip and knee arthroplasties among Medicare beneficiaries in the United States.

We analyzed the variations in the rates of elective total hip and total knee arthroplasties for 1988 in the United States to determine whether the rates correlated with the numbers of surgeons. There were 56,204 total hip arthroplasties and 68,491 total knee arthroplasties, performed in the home states of the patients among all of the Medicare beneficiaries. Medicare beneficiaries include most people who are more than sixty-five years old in the United States and a small proportion of younger people who are eligible for Medicare for other reasons. Seventy-nine per cent of the patients who had had a total hip arthroplasty and 89 per cent of those who had had a total knee arthroplasty had been managed with the operation because of osteoarthrosis. Both operations were most common in the seventy to seventy-four-year age-group. We calculated the rate of operations per 100 beneficiaries for each state and age-adjusted the results. Across all of the states, bilateral procedures constituted 1.6 per cent of the total hip arthroplasties and 4.8 per cent of the total knee arthroplasties. The in-hospital rates of mortality were 0.72 per cent for total hip arthroplasties and 0.45 per cent for total knee arthroplasties. The destinations after discharge from the hospital were similar for the two groups of patients, with more than 65 per cent of the patients being discharged directly to their homes. There were no significant differences among states in terms of the length of stay in the hospital or reimbursement of the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Fatal fat embolism following total condylar knee arthroplasty.

Although fatality from fat emboli syndrome following total knee arthroplasty has been reported, most cases occurred following the insertion of hinged prostheses and few are documented with detailed pathology. The authors present the case of a 75-year-old patient with long-standing rheumatoid arthritis who underwent a total condylar type total knee arthroplasty procedure using an intramedullary femoral alignment system and expired 6 hours following surgery. On autopsy he had multiple organ involvement with fat emboli. Especially with the present use of intramedullary alignment systems and the increasing numbers of one-stage bilateral total knee arthroplasty procedures the potential for this problem must be recognized so that early therapy can be instituted.

Complications and mortality associated with bilateral or unilateral total knee arthroplasty.

The incidence of complications, the need for secondary surgical procedures, and the mortality rate associated with bilateral replacement of the knee performed simultaneously, performed during the same hospitalization, or performed during separate hospitalizations were compared with those after unilateral replacement of the knee. The incidence of complications after 290 simultaneous bilateral procedures was 9.3 per cent, which compares favorably both with the incidence of 7.0 per cent after 228 bilateral procedures that were done during the same hospitalization and incidence of the 12.0 per cent after 234 bilateral procedures that were performed during separate hospitalizations. The incidence for each of these groups compares favorably with the incidence of complications of 11.0 per cent after 501 unilateral procedures. The incidence of reoperation was 2.4, 4.8, 8.5, and 5.6 per cent, respectively, in the four groups, and the incidence of mortality was 5.5, 0.9, 3.8, and 7.0 per cent. None of these differences were statistically significant. These data indicate that the incidence of morbidity and mortality that is associated with simultaneous bilateral total knee arthroplasty is no greater than when the procedure is performed during the same hospitalization or separate hospitalizations.

The long-term results of Stanmore total knee replacements.

Between 1969 and 1971 20 prototypes of the Stanmore total knee prosthesis were used to replace severely arthritic knees in 18 patients. Seven patients died before the final follow-up and one had to have her leg amputated because of deep infection; in none of these patients had the prosthesis become loose. Ten patients (11 knees) were reviewed at least 10 years after operation. There was no significant clinical deterioration in 7 of these 11 surviving knees when the results at one year were compared with those at 10 years.